Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment provided by administrative staff was last updated in December 2024 and did not specify the required staffing levels for each unit, nor did it identify the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked details on staffing requirements for each shift, day, and weekend. A review of the facility's Payroll Based Journaling (PBJ) staffing data revealed excessively low weekend staffing during two consecutive quarters. Interviews with administrative staff confirmed that the assessment was recently updated but still did not include the necessary staffing requirements as outlined by CMS. The facility's own policy, revised in January 2017, requires a documented assessment to determine resources needed for care during all operational periods, including evenings, nights, and weekends. This deficiency affected all 36 residents in the facility.